warfarin and Aortic-Valve-Insufficiency

Takayasu's arteritis (TA) and Crohn's disease (CD) are chronic inflammatory diseases of uncertain etiology. Although co-existence of these rare diseases is estimated to occur in 1 in 10 billion individuals, a theoretically unexpected association has been reported in several patients and it is suggested that those associations may have been more than an unusual coincidence. Herein, we report a case of TA associated with clinically inactive CD. A Japanese woman was diagnosed with colonic CD at the age of 15, developed aortic valve regurgitation at 19, and then presented with general fatigue, low grade fever, and painful sensations in her left arm at 25. She was diagnosed with TA based on computed tomography scanning and magnetic resonance angiography findings, and treatments with prednisolone and cyclosporine were started. Thereafter, valve replacement and right coronary artery bypass graft surgery were performed. The possible pathophysiological mechanism responsible for concurrent existence of TA and CD may be associated with immune disorders. Early diagnosis of vascular lesions for patients with inflammatory bowel disease is highly encouraged.

Topics: Adolescent; Adult; Aortic Valve Insufficiency; Aspirin; Coronary Artery Bypass; Crohn Disease; Cyclosporine; Drug Therapy, Combination; Female; Heart Valve Prosthesis Implantation; Humans; Magnetic Resonance Angiography; Prednisolone; Takayasu Arteritis; Tomography, X-Ray Computed; Warfarin; Young Adult

Topics: Animals; Antibiotic Prophylaxis; Anticoagulants; Aortic Valve Insufficiency; Aortic Valve Stenosis; Bioprosthesis; Calcinosis; Defibrillators, Implantable; Echocardiography, Doppler; Endarterectomy; Endocarditis, Bacterial; Female; Heart Valve Diseases; Heart Valve Prosthesis; Heart Valves; Hemodynamics; Humans; Immunohistochemistry; Magnetic Resonance Imaging; Mitral Valve; Mitral Valve Insufficiency; Mitral Valve Stenosis; Platelet Aggregation Inhibitors; Pregnancy; Pregnancy Complications, Cardiovascular; Pulmonary Artery; Tricuspid Valve Insufficiency; Ventricular Function, Left; Warfarin

Topics: Anticoagulants; Aortic Valve Insufficiency; Arginine; Autoantibodies; Autoimmune Diseases; Female; Fingers; Heart Valve Prosthesis Implantation; Heparin; Hirudins; Humans; Ischemia; Middle Aged; Necrosis; Pipecolic Acids; Platelet Activation; Platelet Factor 4; Postoperative Complications; Raynaud Disease; Recombinant Proteins; Sulfonamides; Thrombocytopenia; Thrombosis; Toes; Warfarin

Topics: Anemia, Hemolytic; Anemia, Hemolytic, Autoimmune; Animals; Anticoagulants; Aortic Valve Insufficiency; Aortic Valve Stenosis; Cardiology; Cattle; Child; Dipyridamole; Dogs; Endocarditis, Bacterial; Extracorporeal Circulation; Female; Heart Valve Prosthesis; History, 15th Century; History, 16th Century; History, 19th Century; History, 20th Century; Humans; Postoperative Complications; Pregnancy; Prosthesis Design; Thromboembolism; Vascular Surgical Procedures; Venoms; Warfarin

To compare the characteristics and outcomes of patients with atrial fibrillation (AF) and aortic stenosis (AS) with patients with AF with mitral regurgitation (MR) or aortic regurgitation (AR) and patients without significant valve disease (no SVD).. Using Rivaroxaban Once-Daily, Oral, Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) data, we analysed efficacy and safety outcomes, adjusting hazard ratios (HRs) for potential confounders using Cox regression analysis.. Among 14 119 intention-to-treat ROCKET AF trial patients, a trial that excluded patients with mitral stenosis or artificial valve prosthesis, 214 had AS with or without other valve abnormalities, 1726 had MR or AR and 12 179 had no SVD. After adjusting for prognostic factors, the composite of stroke, systemic embolism or vascular death increased approximately twofold in patients with AS (AS 10.84, MR or AR 4.54 and no SVD 4.31 events per 100 patient-years, p=0.0001). All-cause death also significantly increased (AS 11.22, MR or AR 4.90 and no SVD 4.39 events per 100 patient-years, p=0.0003). Major bleeding occurred more frequently in AS (adjusted HR 1.61, confidence intervals (CI) 1.03 to 2.49, p<0.05) and MR or AR (HR 1.30, 1.07 to 1.57, p<0.01) than in no SVD, but there was no difference between AS and MR or AR (HR 1.24, 0.78 to 1.97). The relative efficacy of rivaroxaban versus warfarin was consistent among patients with and without valvular disease. Rivaroxaban was associated with higher rates of major bleeding than warfarin in patients with MR or AR (HR 1.63, 1.15 to 2.31).. We found that patients with AF and AS on oral anticoagulants may have distinctly different efficacy and safety outcomes than patients with MR or AR or no SVD.. NCT00403767; Post-results.

Topics: Administration, Oral; Aged; Aged, 80 and over; Anticoagulants; Aortic Valve Insufficiency; Aortic Valve Stenosis; Atrial Fibrillation; Drug Administration Schedule; Female; Humans; Male; Mitral Valve Insufficiency; Retrospective Studies; Rivaroxaban; Stroke; Treatment Outcome; Warfarin

We investigated clinical characteristics and outcomes of patients with significant valvular disease (SVD) in the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) trial.. ROCKET AF excluded patients with mitral stenosis or artificial valve prostheses. We used Cox regression to adjust comparisons for potential confounders. Among 14 171 patients, 2003 (14.1%) had SVD; they were older and had more comorbidities than patients without SVD. The rate of stroke or systemic embolism with rivaroxaban vs. warfarin was consistent among patients with SVD [2.01 vs. 2.43%; hazard ratio (HR) 0.83, 95% confidence interval (CI) 0.55-1.27] and without SVD (1.96 vs. 2.22%; HR 0.89, 95% CI 0.75-1.07; interaction P = 0.76). However, rates of major and non-major clinically relevant bleeding with rivaroxaban vs. warfarin were higher in patients with SVD (19.8% rivaroxaban vs. 16.8% warfarin; HR 1.25, 95% CI 1.05-1.49) vs. those without (14.2% rivaroxaban vs. 14.1% warfarin; HR 1.01, 95% CI 0.94-1.10; interaction P = 0.034), even when controlling for risk factors and potential confounders. In intracranial haemorrhage, there was no interaction between patients with and without SVD where the overall rate was lower among those randomized to rivaroxaban.. Many patients with 'non-valvular atrial fibrillation' have significant valve lesions. Their risk of stroke is similar to that of patients without SVD after controlling for stroke risk factors. Efficacy of rivaroxaban vs. warfarin was similar in patients with and without SVD; however, the observed risk of bleeding was higher with rivaroxaban in patients with SVD but was the same among those without SVD. Atrial fibrillation patients with and without SVD experience the same stroke-preventive benefit of oral anticoagulants.

Topics: Aged; Anticoagulants; Aortic Valve Insufficiency; Atrial Fibrillation; Factor Xa Inhibitors; Female; Hemorrhage; Humans; Male; Mitral Valve Insufficiency; Morpholines; Rivaroxaban; Stroke; Thiophenes; Treatment Outcome; Warfarin

The full homograft root replacement has been regarded as the 'gold standard' for aortic valve replacement (AVR). Xenograft full root AVR may offer similar theoretical advantages, but no prospective randomized trials to compare the two valve substitutes have been reported to date.. A total of 147 patients (mean age 66.2 years; range: 40-82 years) was randomized to undergo either Medtronic Freestyle (group F; n = 80) or homograft (group H; n = 67) root AVR. Coronary artery bypass grafting was associated with root AVR in 55 patients (37.4%). Follow up included routine clinical and echocardiographic assessments.. Overall, there were seven early deaths (4.8%). The early mortality rate for isolated root AVR was 2.1% in group F (1/47) and 2.2% in group H (1/45) (p = NS). There were four late deaths in group F, and two in group H. Actuarial survival was 83+/-5% and 84+/-4% (p = NS) at five years, in groups F and H, respectively. No patient required reoperation on the aortic valve. Overall, there were eight thromboembolic events and six anticoagulant-related bleeding events; these were equally divided between the two groups. After a median follow up of 45 months, most patients in both groups were in NYHA class I, and the mean trans-aortic gradient was 6+/-1 mmHg in group F and 5+/-2 mmHg in group H (p = NS). Mild aortic regurgitation was recorded in 1/26 patients (4%) of group F, and in 1/16 (6%) of group H.. The Medtronic Freestyle porcine xenograft appears to be a good alternative to homografts for full aortic root replacement, at least in the mid term.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Aortic Valve Insufficiency; Aortic Valve Stenosis; Atrial Fibrillation; Bioprosthesis; Female; Follow-Up Studies; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hemodynamics; Humans; Male; Middle Aged; Postoperative Complications; Prospective Studies; Survival Analysis; Transplantation, Homologous; Treatment Outcome; Warfarin

Considering that there is a lack of evidence and guideline-based recommendations on the best preoperative oral anticoagulation management (OAC) for transcatheter aortic valve implantation (TAVI), this cohort study aimed to evaluate bleeding, access site complications, and early safety in patients undergoing TAVI on continued OAC therapy vs no-OAC therapy. Three-hundred forty-four patients submitted to a TAVI procedure (66.3% no-OAC vs 33.7% OAC) were consecutively enrolled. Primary endpoint was defined as in-hospital VARC-2 life-threatening or disabling bleeding. Secondary endpoints were in-hospital VARC-2 major vascular complications and VARC-2 early safety at 30 days. Propensity score matching analysis was performed to reduce potential distribution bias, resulting in 2 well-balanced groups (92 patients in each arm). In the overall cohort, mean age, median EuroScore II, and STS-score were 78.7±7.6 years, 2.9% (1.7-5.9), and 2.3% (1.6-3.6), respectively. Despite being older (78 ± 8 vs 80 ± 6, p = 0.004) and having higher STS score (2.1 vs 2.6, p = 0.001), patients on OAC had similar incidence of in-hospital VARC-2 life-threatening or disabling bleeding (1.3% vs. 0.9%, p = 0.711), major vascular complications (4.8% vs 5.2%, p = 0.888), and VARC-2 early safety at 30 days (10.1% vs 12.1%, p = 0.575). No significant differences in the main outcomes were observed when propensity score matching was applied. In conclusion, the management of patients on OAC submitted to a TAVI procedure is challenging and requires balancing the risk of bleeding with the risk of thromboembolic events. The present study suggests that continued OAC was not associated with increased in-hospital VARC-2 life-threatening or disabling bleeding, major vascular complications, and VARC-2 early safety at 30 days.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aortic Valve Insufficiency; Aortic Valve Stenosis; Atrial Fibrillation; Case-Control Studies; Factor Xa Inhibitors; Female; Humans; Male; Postoperative Complications; Postoperative Hemorrhage; Preoperative Care; Propensity Score; Thromboembolism; Transcatheter Aortic Valve Replacement; Warfarin

Controversy persists regarding the advisability of anticoagulation for the early period after biological surgical aortic valve replacement (AVR). We aim to examine the impact of various antithrombotic regimens on outcomes in a large cohort of biological AVR patients. Records of 1,111 consecutive adult patients who underwent surgical biological AVR at our institution between 2013 and 2017 were reviewed. Outcomes included stroke, bleeding, and death at 3 and 12 months. Treatment regimens included (1) no therapy, (2) anticoagulants (warfarin or Factor Xa inhibitors), (2) antiplateles (various), and (4) anticoagulants + antiplatelets. Kaplan-Meier analysis was used to track outcomes, and Cox-proportional hazards regression models were conducted to analyze effects of different therapies on adverse events. At 3 months, thromboembolic events were low and not significantly different between the no therapy group (2.2%) and anticoagulation (2.8%) or anticoagulation + antiplatelet (3.6%) or all groups (3.7%). The antiplatelet group was just significantly lower, at 2.2%. However, this was driven by non-stroke cardiovascular events in patients with coronary artery disease. The incidence of death at 3 months was low and not significantly different between all groups. At 12 months, there were no thromboembolic benefits between groups, but bleeding events were significantly higher in the anticoagulation group (no therapy (1.4%), anticoagulation (8.4%), antiplatelet (4.5%), anticoagulation + antiplatelet (7.9%)). In conclusion, none of the antithrombotic regimens showed benefits in stroke or survival at 3 or 12 months after biological AVR. Anticoagulation increased bleeding events. Routine anticoagulation after biological AVR appears to be unnecessary and potentially harmful.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Aortic Valve; Aortic Valve Insufficiency; Aortic Valve Stenosis; Aspirin; Atrial Fibrillation; Bicuspid Aortic Valve Disease; Bioprosthesis; Coronary Artery Disease; Factor Xa Inhibitors; Female; Heart Valve Diseases; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hemorrhage; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Mortality; Platelet Aggregation Inhibitors; Postoperative Care; Proportional Hazards Models; Purinergic P2Y Receptor Antagonists; Stroke; Thromboembolism; Warfarin; Young Adult

An 87-year-old female with symptomatic severe aortic stenosis underwent transcatheter valve replacement (TAVR) via the transfemoral approach with a 29mm self-expanding device. Moderate to severe paravalvular regurgitation led to the development of congestive heart failure and hospital readmission 1 month following TAVR. A second 29mm valve was placed to abolish the paravalvular regurgitation. Routine follow-up computed tomography (CT) imaging demonstrated leaflet thickening and decreased leaflet mobility suggesting valve thrombosis, despite adherence to Factor Xa inhibitor. Transthoracic echocardiogram revealed normal transaortic valve gradients. The patient was transitioned to a vitamin K antagonist and repeat imaging 3months later demonstrated progression of thrombosis to an additional leaflet. The case illustrates the potential increased risk of leaflet thrombosis in patients receiving valve-in-valve TAVR procedures, the superiority of multidetector computed tomography to image subclinical leaflet thrombosis, and highlights the need for further investigation in this area.

Topics: Aged, 80 and over; Anticoagulants; Aortic Valve; Aortic Valve Insufficiency; Aortic Valve Stenosis; Bioprosthesis; Echocardiography, Doppler, Color; Echocardiography, Transesophageal; Factor Xa Inhibitors; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Multidetector Computed Tomography; Risk Factors; Thrombosis; Transcatheter Aortic Valve Replacement; Treatment Outcome; Warfarin

A 55-year-old man with Marfan syndrome taking warfarin for anticoagulant therapy after aortic valve replacement developed acute kidney injury (serum creatinine level of 9.01 mg/dL) and gross macrohematuria. Renal biopsy showed red cell casts in the renal tubules, glomerular crescent formation in the glomeruli with immunoglobulin A deposition, and global sclerosis. Based on these findings, the patient was diagnosed with warfarin-related nephropathy with acute kidney injury characterized by immunoglobulin A nephropathy with crescents. The warfarin was withdrawn, and his hematuria and renal function improved without immunosuppressive agents.

Topics: Acute Kidney Injury; Anticoagulants; Aortic Valve Insufficiency; Glomerulonephritis, IGA; Hematuria; Humans; Kidney; Kidney Glomerulus; Kidney Tubules; Male; Marfan Syndrome; Middle Aged; Treatment Outcome; Warfarin

Early antithrombotic therapy after bioprosthetic aortic valve replacement (AVR) is controversial. This study aimed to retrospectively compare between warfarin and aspirin treatment in the 3 months after bioprosthetic AVR for elderly patients more than 60 years old, and to determine the optimal antithrombotic therapy.. This retrospective study included 479 patients in single center from January 1994 to June 2014. Patients were divided into two groups (Wa group, warfarin; As group, aspirin). We searched our computerized clinical database for thromboembolic or bleeding events. Propensity score analysis was conducted to adjust for selection bias.. All patients, except one patient, were followed-up in the out-patient department for 3 months after the operation. In all, 86 propensity-matched patient-pairs were derived. Early operative outcomes were similar in both the groups. There are one patient of thromboembolic event and three patients of bleeding events, but the prevalence was not significantly different (p >0.999).. The incidence of thromboembolic and bleeding events during early 3 months after bioprosthetic AVR were similar in Wa and As groups. If the patient does not have indications of warfarin, early antithrombotic therapy with aspirin only may be easier and more feasible for elderly patients.

Topics: Aged; Aortic Valve; Aortic Valve Insufficiency; Aortic Valve Stenosis; Aspirin; Bioprosthesis; Chi-Square Distribution; Drug Administration Schedule; Female; Fibrinolytic Agents; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hemorrhage; Humans; Logistic Models; Male; Propensity Score; Prosthesis Design; Republic of Korea; Retrospective Studies; Risk Factors; Thromboembolism; Time Factors; Treatment Outcome; Warfarin

Patients with antiphospholipid syndrome (APS) are at high-risk for thrombotic and bleeding complications during cardiopulmonary bypass. We report an APS patient who successfully underwent aortic valve replacement while heparin concentrations were monitored using a patient-specific titration curve using viscoelastic coagulation testing.

Topics: Adult; Anticoagulants; Antiphospholipid Syndrome; Aortic Valve; Aortic Valve Insufficiency; Blood Coagulation Tests; Cardiopulmonary Bypass; Female; Heart Valve Prosthesis Implantation; Heparin; Humans; International Normalized Ratio; Monitoring, Physiologic; Perioperative Care; Postoperative Complications; Postoperative Hemorrhage; Prothrombin Time; Risk; Severity of Illness Index; Thrombosis; Warfarin

Topics: Adult; Aortic Valve; Aortic Valve Insufficiency; Bicuspid Aortic Valve Disease; Bioprosthesis; Drug Resistance; Echocardiography, Doppler; Follow-Up Studies; Heart Valve Diseases; Heart Valve Prosthesis Implantation; Humans; Male; Mutation; Polymerase Chain Reaction; Polymorphism, Genetic; Postoperative Care; Retreatment; Rivaroxaban; Severity of Illness Index; Treatment Outcome; Vitamin K Epoxide Reductases; Warfarin

To define the durability of aortic valve repair (AVRep) and the effect of surgical timing on late survival.. From June 1986 to June 2011, 331 patients underwent elective AVRep for aortic regurgitation (mean age, 53 ± 17 years; 76% men). The repair methods included commissuroplasty (n = 270; 81%), triangular resection and plication (n = 106; 32%), resuspension or cusp shortening (n = 102; 31%), and perforation closure (n = 23; 7%).. In-hospital mortality was 0.6% (2 of 332). Four patients (1%) experienced early repair failure; two underwent repeat repair. Overall survival was 91% and 81% at 5 and 10 years, respectively. After adjusting for age, greater left ventricular end-systolic dimension (per 5 mm; hazard ratio [HR], 1.49; 95% confidence interval [CI], 1.23-1.79; P < .001) and lower ejection fraction (per 5%; HR, 1.42; 95% CI, 1.25-1.63; P ≤ .001) were significant predictors of long-term mortality. Patients with ejection fraction < 50% and left ventricular end-systolic dimension > 50 mm had significantly greater odds of late death (HR, 3.46; 95% CI, 2.05-5.82; P < .001 and HR, 2.08; 95% CI, 1.05-4.12; P = .036, respectively). The risk of aortic valve reoperation was 10% and 21% at 5 and 10 years, respectively. The presence of severe aortic regurgitation (HR, 2.2; 95% CI, 1.1-5.06; P = .02) and more than mild regurgitation at discharge (HR, 5.87; 95% CI, 2.67-12.68; P ≤ .0001) were predictors of late reoperation. Freedom from other valve-related events was 94% and 91% at 5 and 10 years, respectively. Forty-seven patients (21%) with intact valve repair were using warfarin at the last follow-up visit.. AVRep can be performed with excellent late survival and freedom from valve-related events. Awaiting the onset of ventricular dysfunction increases the risk of late mortality, warranting earlier consideration of AVRep for patients with suitable anatomy.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Aortic Valve; Aortic Valve Insufficiency; Cardiac Surgical Procedures; Cardiac Valve Annuloplasty; Female; Hospital Mortality; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Multivariate Analysis; Odds Ratio; Patient Selection; Postoperative Complications; Proportional Hazards Models; Reoperation; Retrospective Studies; Risk Factors; Severity of Illness Index; Stroke Volume; Time Factors; Time-to-Treatment; Treatment Outcome; Ventricular Function, Left; Warfarin; Young Adult

A 55-year-old gentleman diagnosed with severe aortic insufficiency and annuloaortic ectasia underwent modified Bentall procedure using mechanical valve. Anticoagulation therapy with warfarin was introduced after surgery, but sufficient anticoagulation effect was not achieved with a large amount of dosage. After discontinuing the use of the Clostridium butyricum preparation on postoperative day 29, sufficient anticoagulationt effect was obtained within several days. Clostridium butyricum might change the vitamin K production in the intestinal bacterial flora and attenuated the anticoagulation effect of warfarin.

Topics: Anticoagulants; Aortic Valve Insufficiency; Biological Products; Clostridium butyricum; Humans; Male; Middle Aged; Postoperative Period; Warfarin

Topics: Anticoagulants; Aortic Valve Insufficiency; Atrial Fibrillation; Female; Humans; Male; Mitral Valve Insufficiency; Morpholines; Thiophenes; Warfarin

Topics: Anticoagulants; Aortic Valve; Aortic Valve Insufficiency; Aortic Valve Stenosis; Aspirin; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Male; Mitral Valve; Rheumatic Heart Disease; Thromboembolism; Warfarin

This study aimed to report on original aortic valve reconstruction for patients on dialysis.. Aortic valve reconstruction has been performed on 404 cases from April 2007 through September 2011. Among them, 54 cases on haemodialysis were retrospectively studied. Forty-seven patients had aortic stenosis, 5 had aortic regurgitation (AR), and 2 had infective endocarditis. Mean age was 70.2 ± 8.5 years. There were 35 males and 19 females. There were 27 primary aortic valve reconstructions, 11 with CABG, 6 with ascending aortic replacement, 5 with mitral valve repair and 4 with maze. First, in the procedure, harvested pericardium was treated with 0.6% glutaraldehyde solution. After resecting the cusps, we measured the distance between commissures with original sizing instrument. Then, the pericardium was trimmed with the original template. Three cusps were sutured to each annulus.. Peak pressure gradient averaged to 66.0 ± 28.2 mmHg preoperatively, and decreased to 23.4 ± 10.7, 13.8 ± 5.5 and 13.3 ± 2.3 mmHg, 1 week, 1 year, and 3 years after the operation, respectively. No calcification was detected with echocardiographic follow-up. Recurrence of AR was not recorded with the mean follow-up of 847 days except for 1 case reoperated on for infective endocarditis 2.5 years after the operation. Three hospital deaths were recorded due to non-cardiac causes. Other patients were in good condition. There was no thromboembolic event.. Medium-term results are excellent. Since warfarin for dialysis patients becomes problematic, a postoperative warfarin-free status is desirable. Aortic valve reconstruction can provide patients with a better quality of life without warfarin.

Topics: Aged; Anticoagulants; Aortic Valve Insufficiency; Aortic Valve Stenosis; Cardiac Valve Annuloplasty; Female; Fixatives; Glutaral; Humans; Kaplan-Meier Estimate; Kidney Diseases; Male; Middle Aged; Pericardium; Recurrence; Renal Dialysis; Reoperation; Retrospective Studies; Time Factors; Tissue Fixation; Transplantation, Autologous; Treatment Outcome; Warfarin

Topics: Age Factors; Aged, 80 and over; Anticoagulants; Aortic Valve Insufficiency; Atrial Appendage; Cardiac Catheterization; Heart Valve Prosthesis Implantation; Humans; Male; Ultrasonography; Warfarin

Topics: Anticoagulants; Aorta; Aortic Valve; Aortic Valve Insufficiency; Cardiac Surgical Procedures; Factor VIIIa; Heart Valve Prosthesis Implantation; Humans; Male; Middle Aged; Perioperative Care; Postoperative Care; Preoperative Care; Thrombosis; von Willebrand Disease, Type 2; Warfarin

Topics: Aged; Alcohol Withdrawal Delirium; Anticoagulants; Aortic Aneurysm; Aortic Dissection; Aortic Valve Insufficiency; Atrial Fibrillation; Delayed Diagnosis; Diagnostic Errors; Dyspnea; Edema; Epilepsy, Tonic-Clonic; Fatal Outcome; Heart Failure; Heart Valve Prosthesis; Humans; Hypertension; Male; Postoperative Complications; Psychomotor Agitation; Tomography, X-Ray Computed; Warfarin

Anticoagulant therapy with warfarin is recommended in the early postoperative period after bioprosthetic aortic valve replacement (bAVR). However, some studies have addressed questions about its necessity. We evaluated postoperative coagulant activity data including prothrombin time-international normalized ratio (PT-INR) and thrombin-antithrombin III complex (TAT), measured every month in 21 bAVR patients during the 1st postoperative year. The results were divided into four time intervals after the operation: 1-3 months (P-1), 4-6 (P-2), 7-9 (P-3), and 10-12 (P-4). Warfarin, which was administrated in the first six months, in combination with aspirin, 100 mg, was started targeting PT-INR of 1.75-2.25. The values of TAT in P-1, P-2, P-3 and P-4 were 1.35+/-1.07 (ng/ml), 0.82+/-0.55, 0.81+/-0.78, and 0.72+/-0.62, respectively, showing significantly high values in P-1. Furthermore, the TAT values of P-1 and P-2 within the range of PT-INR from 1.75 to 2.25 were 1.15+/-0.71 (ng/ml) and 0.79+/-0.52; demonstrating statistical difference between them. The coagulant activity assessments suggest that warfarin administration during the first three months is necessary for bAVR patients to keep the TAT within the normal range.

Topics: Aged; Aged, 80 and over; Anticoagulants; Antithrombin III; Aortic Valve Insufficiency; Aortic Valve Stenosis; Biomarkers; Bioprosthesis; Blood Coagulation; Drug Administration Schedule; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; International Normalized Ratio; Male; Peptide Hydrolases; Prosthesis Design; Prothrombin Time; Time Factors; Treatment Outcome; Warfarin

Prosthetic valve thrombosis (PVT) represents a serious and potentially lethal complication. It can be attributed more frequently to inadequate anticoagulant therapy. We present a case of acute aortic mechanical valve thrombosis six months after implantation. The patient discontinued oral anticoagulation after being discharged following the primary operation. Two days after reinitiating warfarin as an outpatient, he developed acute valve thrombosis presenting with symptoms and signs of cardiac failure. He was managed with intravenous thrombolysis with a recombinant plasminogen activator which resulted in immediate resolution of thrombus and clinical improvement. A paradox procoagulant effect of warfarin is evident on the first one or two days after initiation of therapy. A 'bridging' protocol with unfractionated or low molecular weight heparin (LMWH) should be considered, according to recently published guidelines, until warfarin reaches therapeutic levels and exerts an antithrombotic effect.

Topics: Acenocoumarol; Acute Disease; Adult; Anticoagulants; Aortic Valve Insufficiency; Endocarditis; Fibrinolytic Agents; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Heparin; Humans; Male; Medication Adherence; Tenecteplase; Thrombolytic Therapy; Thrombosis; Tissue Plasminogen Activator; Treatment Outcome; Warfarin

Leaflet opening angles of ATS valves in vivo tend to be less than those reported by the manufacturer, and there is a wide variation in opening angles even among valves of the same size.. Leaflet movement of aortic ATS valves was evaluated by cineradiography in 77 patients. The mean period from valve replacement to cineradiography was 40.2 months, and during that period, the ATS valve was replaced due to prosthetic valve obstruction in 1 of the 77 patients.. In 76 patients with a normally functioning ATS valve, the mean opening angle of 19-mm valves (66.3 degrees +/- 2.3 degrees) was significantly less (p < 0.0001) than that of ATS valves 21 mm or larger (72.2 degrees +/- 3.8 degrees in 21-mm, 72.4 degrees +/- 2.8 degrees in 23-mm, and 72.8 degrees +/- 2.9 degrees in 25-mm valves). No significant differences were found in the opening angles of ATS valves 21 mm or larger, and the opening angles exceeded 65 degrees in all 69 patients with valves in this category. In one case of obstruction in a 21-mm valve, the opening angle was 57.5 degrees. The closing angle was 24.9 degrees +/- 1.3 degrees, which corresponded well with the manufacturer's in vitro data.. The opening angle in the 19-mm ATS aortic valve is significantly less than that in valves 21 mm or larger, and an opening angle of less than 65 degrees probably indicates prosthetic valve obstruction in aortic ATS valves sized 21 mm or larger.

Topics: Adolescent; Adult; Aged; Anticoagulants; Aortic Valve; Aortic Valve Insufficiency; Aortic Valve Stenosis; Aspirin; Cardiac Surgical Procedures; Cineradiography; Comorbidity; Echocardiography, Doppler; Equipment Design; Female; Heart Valve Prosthesis; Hemorheology; Humans; Male; Middle Aged; Motion; Platelet Aggregation Inhibitors; Postoperative Complications; Postoperative Period; Prosthesis Failure; Reoperation; Thromboembolism; Warfarin

Indications to prosthetic aortic valve implantation in patients with aortic stenosis or aortic regurgitation or both stenotic or regurgitant aortic valve, who present without symptoms, are controversial. We present the case of an asymptomatic patient with combined severe aortic stenosis and an equally important insufficiency, undergoing surgery for valve substitution with a bileaflet prosthesis. After surgery he was treated with warfarin according to the doses recommended and underwent follow-up with clinical and echocardiographic exams. Eight months after intervention the patient had an embolic stroke with aphasia and right hemiplegia, despite the therapeutic level of INR. At present, even though he has partly recovered motor function, he reports a noteworthy decline in life quality, because of the persistent speech difficulties. We use this case as the starting point for a discussion of the chance of referring patients affected by aortic valvulopathy to valve substitution, in the absence of symptoms.

Topics: Anticoagulants; Aortic Valve Insufficiency; Aortic Valve Stenosis; Heart Valve Prosthesis Implantation; Humans; Male; Middle Aged; Postoperative Care; Prognosis; Severity of Illness Index; Time Factors; Warfarin

Patients with mechanical heart valves are treated with oral anticoagulant therapy in order to minimize the risk of thromboembolism. During invasive procedures it is recommended to temporarily discontinue the oral anticoagulant therapy and substitute with injections of low-molecular-weight heparin. We describe a case where a patient discontinued the oral anticoagulant therapy and had no substitution with low-molecular-weight heparin. The patient had an embolism to the coronary arteries causing progressive heart failure, and the patient was subsequently heart transplanted.

Topics: Adult; Anticoagulants; Aortic Valve Insufficiency; Coronary Thrombosis; Heart Transplantation; Heart Valve Prosthesis; Humans; Male; Substance Withdrawal Syndrome; Thromboembolism; Warfarin

A 53-year-old woman suffered intracranial hemorrhage from a cerebellar tumor several days after aortic valve replacement. Surgical intervention was not performed because the patient refused blood infusion for religious reasons (Jehovah's Witness). Instead, the anticoagulation therapy was interrupted for a week, and the patient was conservatively treated with administration of mannitol and steroid. The anticoagulation therapy was restarted 7 days after the hemorrhage. The intratumoral hemorrhage did not recur, and no systemic embolism occurred. The tumor was treated with gamma knife radiosurgery 6 weeks after the hemorrhage, under the radiological diagnosis of meningioma. Anticoagulation therapy is routinely used for patients following cardiac surgery to decrease the risk of thromboembolic complications, but also increases the risk of hemorrhagic events which often involve the central nervous system. Temporary discontinuation of anticoagulation therapy is an option for intratumoral hemorrhage in patients with replacement heart valves, and patients with known brain tumors should be informed about the risk of intracranial hemorrhage before cardiac surgery.

Topics: Adrenal Cortex Hormones; Anticoagulants; Aortic Valve; Aortic Valve Insufficiency; Cerebellar Neoplasms; Cerebral Hemorrhage; Cranial Fossa, Posterior; Female; Heart Valve Prosthesis Implantation; Heparin; Humans; Magnetic Resonance Imaging; Mannitol; Meningeal Neoplasms; Meningioma; Middle Aged; Postoperative Complications; Radiosurgery; Thromboembolism; Warfarin

The choice of the most appropriate substitute in children with irreparable aortic valve lesions remains controversial. The aim of this study was to assess early and late outcomes following aortic valve replacement (AVR) with mechanical prostheses in children.. Fifty-six patients (42 male, 14 female, mean age 11.2, range 1-16 years) undergoing AVR with mechanical prostheses between October 1972 and January 1999 were evaluated. Thirty-six patients (64.2%) underwent previous cardiac surgery. Disease aetiology was congenital in 47 patients (congenital aortic stenosis in 33, and other congenital abnormalities in 14) (83.9%), infective in four (7. 1%), rheumatic in two (3.4%), and three (5.3%) had connective tissue disorders. Haemodynamic indication for AVR was aortic regurgitation (AR) in 24 (42.8%), aortic stenosis (AS) in 22 (39.2%) and mixed disease in ten (17.8%). Twenty-eight patients (50.0%) were in New York Heart Association (NYHA) class III-IV before surgery. Concomitant procedures were performed in 31 patients (55.3%), including aortic root enlargement in 28 (50%). The mean size of implanted valves was 22.4 mm (range 17-27 mm). All patients received long-term anticoagulation treatment with sodium warfarin, aiming to maintain an international normalized ratio (INR) between 2.5-3.0. The mean follow-up was 7.3 years (range 0-26, total 405 patient-years).. Operative mortality was 5.3% (three patients). Three patients developed complete heart block requiring pacing, two of them permanently. Late events included valve thrombosis (one), transient stroke (one), paravalvular leak of a mitral prosthesis (one), aneurysm of sinus of Valsalva (one) and pannus ingrowth (one). There was no major haemorrhagic event. Five patients required re-operation (8.9%), but none due to outgrowth of the valve. Regarding actuarial freedom from thrombo-embolism, any valve-related event and re-operation at 20 years was 93, 86.6 and 86. 4%. There were three late deaths. Actuarial survival, including operative mortality, at 10 and 20 years was 91 and 84.9%. The actuarial survival for the group of the patients with congenital AS (n=33) at 10 and 20 years was 93.5%, whereas for the children with other congenital heart problems (n=14) this was 85.7 and 64.3% (P=0. 09). At the latest clinical evaluation, 44 children were in NYHA class I and six were in class II. The mean gradient across the aortic prosthetic valve on echocardiography was 17.9 mmHg (range 0-47 mmHg).. Mechanical AVR, with enlargement of the aortic root if necessary, remains an excellent treatment option in children. It is associated with acceptable operative mortality, low incidence of late events and re-operation, and provides good long-term survival. It clearly represents a good alternative to available biological substitutes, including the pulmonary autograft (Ross procedure).

Topics: Actuarial Analysis; Anticoagulants; Aortic Valve; Aortic Valve Insufficiency; Aortic Valve Stenosis; Child; Female; Follow-Up Studies; Heart Defects, Congenital; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Male; Prosthesis Design; Warfarin

Self-monitoring of anti-vitamin K treatment by patients with heart valve prostheses is a good alternative to hospital control. Self-monitoring at home allows patients more freedom and opportunity to take greater responsibility for their treatment. Experience from over a years' complication-free treatment of 12 patients is reported in the article.

Topics: Adult; Aged; Anticoagulants; Aortic Valve Insufficiency; Aortic Valve Stenosis; Blood Coagulation Tests; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Male; Middle Aged; Patient Education as Topic; Prothrombin Time; Quality of Life; Self Care; Vitamin K; Warfarin

Aortic root replacement (ARR) is a technically demanding procedure that can be performed using a variety of prosthetic devices. Root replacement in the young, but grown-up, patient poses unique problems in terms of the long-term outcome and active lifestyle that must be guaranteed by this operation. To identify the "ideal" substitute for ARR in the young, clinical results in teenagers and young adults (<35 years) operated on in the past two decades were reviewed.. Thirty-eight patients younger than 35 years underwent ARR between January 1980 and December 1996. Eighteen patients, aged 30+/-5 years, had ARR with composite graft (group 1), whereas 20 patients, aged 28+/-6 years, had ARR with aortic homografts or pulmonary autografts (group 2). Primary indication for the operation was aortic insufficiency with anuloaortic ectasia (12 of 18) in group 1 and aortic insufficiency with or without anuloaortic ectasia (16 of 20) in group 2. Urgent ARR was required in 3 (17%) group 1 patients and 1 (5%) group 2 patient (p = 0.01).. Operative deaths were 2 (11%) in group 1, caused by hemorrhage and low output, and none in group 2. There were 4 (25%) late deaths in group 1, caused by embolism (2), hemorrhage, and myocardial infarction, and 1 (5%) in group 2, caused by arrhythmia. Survival was 81% +/- 9%, and 55%+/-18% at 2 and 10 years in group 1 versus 94%+/-5% at 2 years in group 2 (p = 0.04). Freedom from valve-related events was 93%+/-6% and 62%+/-18% at 2 and 10 years in group 1 versus 100% at 2 years in group 2 (p = 0.02). Freedom from reoperation in group 1 was 75% +/- 22% at 10 years, whereas no reoperations were done in group 2. Seven (58%) group 1 patients versus 1 (5%) group 2 patient were on cardiac medications (p = 0.001), and 11 (92%) group 1 patients versus no group 2 patients were on warfarin therapy at follow-up. All survivors were back to school or prior employment.. Survival early after ARR does not differ depending on the type of prosthesis. Valve-related events are common, and reoperation may be needed late after ARR with composite grafts. Despite limited follow-up with biologic devices, the prevalence of complications with composite grafts makes homograft or autograft ARR preferable in adolescents and young adults.

Topics: Adolescent; Adult; Age Factors; Anticoagulants; Aortic Valve; Aortic Valve Insufficiency; Bioprosthesis; Cardiac Output, Low; Cause of Death; Embolism; Female; Follow-Up Studies; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Life Style; Longitudinal Studies; Male; Myocardial Infarction; Postoperative Complications; Postoperative Hemorrhage; Pulmonary Valve; Reoperation; Retrospective Studies; Risk Factors; Survival Rate; Transplantation, Autologous; Transplantation, Homologous; Treatment Outcome; Warfarin

A 45-year-old woman with prosthetic valves replacement, was admitted with severe headache and vomiting one month after starting danazol treatment at 300 mg per day. She was receiving long-term anticoagulation with warfarin and dipyridamole, taking 3.5 mg and 300 mg per day respectively. The patient's thrombotest value was less than 6% at the time of admission. Cranial CT revealed subarachnoid hemorrhage. Warfarin and danazol treatment ware discontinued with replenishment of vitamin K. Recovery was uneventful. Danazol is 2, 3 isoxazol derivative of 17-alpha-ethinyl testosterone. As such, it shares the property of C 17 alkylated steroids in potentiating the action of coumarin. It is suggested that danazol affects the turnover of vitamin-K-dependent clotting factors, an impairment of synthesis being a likely mechanism. The possible hazard of the potentiating effect of danazol on warfarin should be widely appreciated.

Topics: Aortic Valve Insufficiency; Blood Coagulation; Danazol; Drug Therapy, Combination; Female; Heart Valve Prosthesis; Humans; Middle Aged; Mitral Valve Insufficiency; Subarachnoid Hemorrhage; Warfarin

Topics: Adult; Aortic Valve; Aortic Valve Insufficiency; Aortic Valve Stenosis; Female; Heart Valve Prosthesis Implantation; Heparin; Humans; Intracranial Embolism and Thrombosis; Pregnancy; Pregnancy Complications, Cardiovascular; Warfarin

Topics: Adult; Aortic Valve Insufficiency; Aortic Valve Stenosis; Heart Valve Prosthesis; Hematoma, Subdural; Humans; Male; Mitral Valve Stenosis; Postoperative Complications; Warfarin

The Starr-Edwards non-cloth-covered silicone ball (Model 1260) aortic valve prosthesis has been widely used for over 15 years and remains a standard against which newer values are compared. To define more completely the performance characteristics of this prosthesis, this study (including 449 patients) analyzed the long-term function of this specific valve over a cumulative total of 2,896 patient-years (pt-yrs) of follow-up which extended beyond 13 years. Expressed in both actuarial (% [+/- standard error of the mean] free at 10 years) and linearized (%/pt-yr) terms, respectively, valve-related complications occurred at the following rates: thromboembolism, 76 +/- 3 and 2.7; anticoagulant-related hemorrhage, 74 +/- 3 and 3.1; prosthetic valve endocarditis, 92 +/- 2 and 0.9; reoperation, 90 +/- 2 and 1.1; valve failure, 82 +/- 2 and 2.2; all valve-related morbidity and mortality, 51 +/- 3 and 6.0; and valve-related death, 88 +/- 2 and 1.3. Thirteen percent of hospital and 18% of late deaths were due to valve-related causes. No case of structural failure was documented. This prosthesis has an admirable structural durability record out to 13 years, and its long-term performance is satisfactory, albeit not optimal. Despite the indestructable design and construction of this mechanical valve substitute, 12% +/- 2% of patients had died of valve-related complications by 10 years, and fully 49% +/- 3% had had some form of serious valve-related complication. The long-term data reported herein can be used for analytical comparison when follow-up of patients with newer mechanical prostheses and tissue bioprostheses reaches 10 years to elucidate whether or not these newer valves truly represent improvements and which type of valve substitute proffers the most possible net benefit to the patient.

Topics: Actuarial Analysis; Adult; Aged; Aortic Valve; Aortic Valve Insufficiency; Aortic Valve Stenosis; Endocarditis; Equipment Design; Equipment Failure; Female; Follow-Up Studies; Heart Valve Prosthesis; Hemorrhage; Humans; Male; Middle Aged; Reoperation; Thromboembolism; Warfarin

Advanced actuarial techniques are used to analyze late results in 912 patients who had isolated mitral or aortic valve replacement with ball valve prostheses from 1965 to 1974. Experience with noncloth-covered and cloth-covered valves is compared in terms of late survival, rate of thromboembolic complications and reoperation and the influence of anticoagulation. The cloth-covered prostheses have substantially reduced the incidence of emboli after mitral valve replacement (1.9 vs. 6 emboli per 100 patient years) and have thus far eliminated emboli after aortic valve replacement in patients receiving warfarin. Patients with a cloth-covered aortic valve who did not receive warfarin had nine emboli per 100 patient years. The safety of cloth-covered valves is clearly enhanced by warfarin therapy; the efficacy of anti-platelet drugs is still uncertain. Strut cloth wear was found at reoperation in 10 patients. This should be prevented in the new model 2400 composite strut ("track") valve by a narrow metal track on the inner surface of each strut. The substantial recent reductions in operative mortality and in prosthesis-related complications pose important questions regarding timing of operations and selection of prostheses. These decisions must be individualized for each patient on the basis of a thorough analysis of late results using modern statistical methods.

Topics: Aortic Valve; Aortic Valve Insufficiency; Aortic Valve Stenosis; Evaluation Studies as Topic; Female; Follow-Up Studies; Heart Valve Diseases; Heart Valve Prosthesis; Hemolysis; Humans; Male; Mitral Valve; Mitral Valve Insufficiency; Mitral Valve Stenosis; Polyethylene Terephthalates; Polypropylenes; Polytetrafluoroethylene; Prosthesis Design; Risk; Stress, Mechanical; Thromboembolism; Time Factors; Warfarin

Thromboembolism continues to complicate the course of patients following aortic valve replacement. In patients with prosthetic and homograft mitral valves, platelet survival time has been shown to correlate with occurrence of thromboembolism. This study extends these observations to patients with aortic valve disease. Platelet survival time was measured (by the chromium-51 method) in 73 patients with aortic valve disease. Eighteen patients were studied preoperatively and had platelet survival times of 3.4 plus or minus 0.14 days (mean plus or minus standard error of the mean), almost the same as normal (3.7 plus or minus 0.4 days). Platelet survival time was shortened (P less than 0.001) following aortic valve replacement with Starr-Edwards prosthesis - Model 1000: 2.5 plus or minus 0.13 days (N = 6); Model 1200-1260: 3.0 plus or minus 0.10 (n = 14); model 2300-2320: 3.0 plus or minus 0.15 days (N = 9) - and with stented aortic homografts: 3.0 plus or minus 0.10 days (N = 16). Platelet survival time was normal following aortic valve replacement in patients with directly sewn aortic homografts 3.7 dats plus or minus 0.24 days (N = 10). Eleven patients with Starr-Edwards prostheses had a history of thromboembolism and all also showed shortened platelet survival time (2.7 plus or minus 0.12 days, P less than 0.001), a measurement which was significantly different (P less than 0.01) from the 18 patients with Starr-Edwards prostheses and no thromboembolism (3.0 plus or minus 0.09 days). Platelet suppressant therapy prolonged platelet survival in eight patients with Starr-Edwards devices, thromboembolism, and shortened platelet survival time. These results suggest that insertion of Starr-Edwards valves and stented aortic homografts alter platelet survival time but that direct homografts do not. A correlation between occurrence of thromboembolism after aortic valve replacement and shortened platelet survival time has been shown.

Topics: Adult; Aortic Valve; Aortic Valve Insufficiency; Aortic Valve Stenosis; Aspirin; Blood Platelets; Cell Survival; Chromium Radioisotopes; Dipyridamole; Female; Heart Valve Prosthesis; Humans; Male; Middle Aged; Sulfinpyrazone; Thromboembolism; Time Factors; Transplantation, Autologous; Warfarin

Advanced actuarial techniques are used to analyze early and late results in a closely followed series of 396 patients who received a cloth-covered, composite-seat aortic prosthesis. Late mortality and various complications are carefully assessed, and most late deaths are seen to be unrelated to the prosthesis. One hundred sixteen patients with Model 2310-2320 prostheses who received warfarin postoperatively had no thromboembolic complications in 360 patient-years of follow-up (average, 3.1 years per patient); 134 patients who had the same prosthesis but did not receive warfarin had 9 emboli per 100 patient-years (average follow-up, 1.7 years per patient; total, 228 patient-years). By comparison, in 9 years' experience with non-cloth-covered Model 1200-1260 valves, 132 patients had 4.0 emboli per 100 patient-years (average follow-up, 5.1 years; total, 673 patient-years). The safety of cloth-covered valves is clearly enhanced by concomitant use of anticoagulants; the possibility that antiplatelet drugs may suffice has not yet been demonstrated. Strut cloth wear was found at reoperation in 10 patients. The Model 2400 composite strut ("track") valve with a narrow metal track on the inner surface of each strut prevents this complication.

Topics: Adolescent; Adult; Aged; Aortic Valve Insufficiency; Aortic Valve Stenosis; Female; Follow-Up Studies; Heart Valve Prosthesis; Humans; Male; Middle Aged; Postoperative Complications; Thromboembolism; Warfarin

Topics: Adolescent; Adult; Aortic Valve Insufficiency; Atrial Fibrillation; Cerebral Hemorrhage; Child; Death, Sudden; Endocarditis, Bacterial; Female; Follow-Up Studies; Heart Valve Diseases; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve Insufficiency; Mitral Valve Stenosis; Myocardial Infarction; Postoperative Complications; Thromboembolism; Tricuspid Valve Insufficiency; Warfarin

Topics: Adult; Age Factors; Aged; Aortic Valve Insufficiency; Aortic Valve Stenosis; Cardiac Surgical Procedures; Female; Gastrointestinal Hemorrhage; Humans; Male; Middle Aged; Mitral Valve Insufficiency; Peptic Ulcer Hemorrhage; Postoperative Complications; Sex Factors; Warfarin

Topics: Abnormalities, Drug-Induced; Adult; Anticoagulants; Aortic Valve; Aortic Valve Insufficiency; Female; Fetal Death; Heart Valve Prosthesis; Heparin; Humans; Labor, Obstetric; Mitral Valve; Mitral Valve Insufficiency; Phenindione; Postoperative Complications; Pregnancy; Pregnancy Complications, Cardiovascular; Thromboembolism; Warfarin

Aortic valve replacement with the University of Cape Town lenticular prosthesis was performed in 149 patients during a six-year period, almost all patients being severely disabled with advanced heart disease. There was a hospital mortality of 12 per cent. Bacterial endocarditis was a serious complication and accounted for three hospital and five long-term deaths. The survivors were followed for periods of up to 72 months (average 24), the minimum period of observation being six months. There were 23 late deaths due to heart disease, of which 5 where due to myocardial failure. Myocardial failure unrelieved or only temporarily alleviated by the operation occurred in three surviving patients. The main problems have been sudden death and systemic embolism. Some of the cases of sudden death were due to coronary artery embolism, but in a number the cause could not be determined even at necropsy, and they were presumed to be due to arrhythmia. Both complications appeared to be related to valve design. A bare steel seat was associated with a high incidence of both complications, whereas a woven Dacron-velour cloth-covered seat almost eliminated embolism and reduced the incidence of sudden death. Long-term anticoagulant therapy appears to be of no real value with the cloth-covered valve. Gratifying results were obtained in the surviving patients with loss of all symptoms in 80 per cent and improvement in almost all patients. This improvement or relief of symptoms was maintained in most patients throughout the period of study.

Topics: Adolescent; Adult; Aged; Alloys; Anemia, Hemolytic; Angina Pectoris; Aortic Valve; Aortic Valve Insufficiency; Aortic Valve Stenosis; Arrhythmias, Cardiac; Cardiovascular Diseases; Child; Endocarditis, Bacterial; Female; Follow-Up Studies; Heart Valve Prosthesis; Humans; Male; Middle Aged; Phenindione; Polymers; Postoperative Complications; Thromboembolism; Warfarin

Review of the 74 patients undergoing aortic valve replacement with a Starr-Edwards ball-valve prosthesis between October 1963 and December 1967 showed that 16 died during surgery or within the first month after operation, usually owing to myocardial failure; and there were nine late deaths. The remaining patients developed few major complications, and the long-term results of operation are considered satisfactory, no patient being grossly incapacitated and most of them are leading active, symptom-free lives.

Topics: Adolescent; Adult; Aged; Aortic Rupture; Aortic Valve Insufficiency; Aortic Valve Stenosis; Cardiac Tamponade; Female; Heart Valve Prosthesis; Humans; Male; Middle Aged; Myocardial Infarction; Postoperative Complications; Thrombosis; Warfarin

Topics: Alcoholism; Aortic Valve Insufficiency; Disulfiram; Drug Synergism; Humans; Male; Middle Aged; Warfarin